1. Nasal Polyps
Mr Stephen O’Hanlon

2. Introduction
Abnormal lesions that emanate from portion of nasal mucosa or paranasal sinuses
Benign polyps
Other benign or malignant tumours

3. Nasal polyps
Endoscopic view of left nasal cavity. Polyp protruding from uncinate process

4. Nasal polyps
Left anterior nasal cavity showing an antro-coanal polyp. Sucker is pushing inferior turbinate to one side

5. Pathophysiology Unknown Chronic inflammation
Autonomic nervous system dysfunction
Genetic predisposition
Allergic verses non-allergic

6. Pathophysiology Associated with allergic conditions 20-50% have asthma
Allergic rhinitis
8-26% have aspirin intolerance
50% have alcohol intolerance

7. Pathophysiology Non allergic conditions
Cystic Fibrosis 6-48% have polyps
AFS 85% have polyps
Young syndrome
Churg-Strauss syndrome

8. Pathophysiology
Coronal CT scan of sinuses of patient with cystic fibrosis

9. Pathophysiology
Allergic fungal sinusitis

10. Pathophysiology
Polyps are more common in patients with non-allergic asthma (13%) than allergic asthma (5%)
3000 atopic patients 0.5% have polyps
Norlander et al (1999)

11. Pathophysiology Various theories Bernstein theory Vasomotor theory
Epithelia rupture theory

12. Pathophysiology Bernstein theory
Inflammatory changes in lateral nasal wall or sinus mucosa
Polyps originate from contact area
Ulceration, reepithelialisation and new gland formation
Inflammatory processes from epithelial cells, endothelium and fibroblasts
Integrity of sodium channels affected

13. Frequency Adults 1-4% Children 0.1% All races and social classes
M/F 2-4:1 in adults
Increasing incidence with age

14. Presentation Asymptomatic Airway obstruction Postnasal drip
Dull headaches
Snoring
Rhinorhoea
Hyposmia / Anosmia
Epistaxis (often other lesion)
Obstructive sleep apnoea
Craniofacial abnormalities
Optic nerve compression

15. Differential Encephalocoeles Gliomas Dermoid tumours Haemangiomas
Papillomas / transitional cell papillomas
Nasopharyngeal angiofibromas
Rhabdomyosarcomas
Lymphomas
Neuroblastomas
Sarcomas
Chordomas
Nasopharyngeal carcinomas

16. Differential
Intranasal gioma in a 5 year old

17. Differential
Nasal papilloma arising from septum

18. Differential
Rhabdomyosarcoma affecting posterior ethomids, orbit, left middle fossa and skull base of cavernous sinuses

19. Differential
A rare cause of polyps?

20. Investigations Sweat test RAST / skin testing Nasal smear Microbiology
Eosinophils (allergic component)
Neutrophils (chronic sinusitis)

21. Investigations Coronal CT scan MRI scan Flexible nasendoscopy
Rigid nasendoscopy

22. Investigations
Coronal CT scan through anterior sinuses. Opacification of left maxillary sinus, opacification of inferior half of nasal cavity. Due to antro coanal polyp.

23. Histological findings
Pseudostratified ciliated columnar epithelium
Thickened epithelial basement membrane
Oedematous stroma

24. Histological findings
Eosinophils in 80-90% of polyps
Eosinic granules - LTs, ECP, PAF, peroxidases, etc
Epithelial damage, ciliostasis
LT-A4 mucosal swelling and hyperresponsiveness
Increased lifespan (12 days vs 3 days)
?due to IL5 blockage of Fas receptors

25. Histological findings
Neutrophils in 7% of polyps
CF, primary ciliary dyskinesia, Youngs syndrome
Poor response to standard treatment
Non IgE mediated degranulation

26. Histological findings
Histamine - level in polyps times higher than serum levels
Immunoglobulins normally unaffected. IgA2 and IgE higher in middle and inferior turbinate polyps

27. Treatment Oral and nasal steroids Immunotherapy Diet (no effect)
High dose prednisolone and nasal steroid for 20 days will eliminate 50% of polyps
Lower bioavailability in modern nasal steroids
Poor response in certain groups
Intranasal injection not effective
Immunotherapy
Diet (no effect)

28. Treatment Traditional polypectomy Microdebrider
Endoscopic sinus surgery
Recurrence
Multiple small polyps common
Large and antro-coanal less so

29. Nasal polypectomy
Nasal polyp. Stalk attached to medial maxillary wall

30. Nasal Polypectomy
Microdebrider entering left middle meatus

31. Any questions?

32. Summary Common condition in adults Aetiology not fully understood
Majority are not allergic in nature
Medical treatment can be effective
Even with surgery, recurrence is common